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In response to the article published by Monti et al 1 regarding the clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies, we started to collect similar data from our patients with chronic rheumatic disease as well, to be able to aid in providing preliminary data on how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) impacts our patients with immunosuppressive therapies. The first officially reported case in the Netherlands originates from 27 February in the province of North Brabant.2 A few weeks later, after community screening and case identification, it came apparent that the virus had to be present in the community already 2 weeks before the first official case was described. Two and a half million people inhabit North Brabant. In this province, Carnival was celebrated between 21 and 26 February. Carnival is a public celebration in regions of Catholic descent, involving parades and street parties in which at least 200 000 people participate in various cities and villages. It is thought that these public celebrations allowed SARS-CoV-2 to rapidly spread in communities, making North Brabant, together with Limburg (an adjacent province), the regions with the highest number of infections in the Netherlands. Our hospital is situated in Eindhoven and Veldhoven, in the province of North Brabant. The number of proven SARS-CoV-2 infections, COVID-19-associated hospital admissions and COVID-19-related deaths is recorded for the general population per municipality and made public by the Dutch National Institute For Public Health and Environment. During the period of 1 March 2020–25 April 2020, we recorded the data of all patients who contacted our clinic with positive reverse transcription (RT)-PCR tests and questions about treatment, as well as the patients with a chronic rheumatic disease who were admitted to the emergency room or clinical wards. This allows for a preliminary comparison between the number of patients from our outpatient clinic that are admitted for severe SARS-CoV-2 disease and the number of admissions in the general population surrounding our hospital.
In total, we identified 27 patients of which 19 tested positive by RT-PCR in our centre, and others were deemed to be positive on the basis of a family member with confirmed SARS-CoV-2 and typical symptoms (eg, bilateral pneumonia, dyspnoea and dry cough) or had a positive test result confirmed by their general practitioner. The characteristics of all the patients are provided in table 1. Since most patients are admitted to their local hospitals, the number of SARS-CoV-2 admissions is a reliable number for our population.
The number of SARS-CoV-2-related hospital admissions in the general population of the municipalities surrounding our hospital is between 60 and 325 per 100 000 inhabitants (0.06%–0.32%). In our population of 7600 patients with chronic rheumatic disease, 14 were admitted to the hospital due to SARS-CoV-2 infection (0.18% of the total outpatient population), which is very similar to the general population.
Of the 27 patients who were identified, 6 died; all of the patients were male and suffered from rheumatoid arthritis and were treated with methotrexate. Three of the deceased patients were not treated for COVID-19, out of their own personal beliefs of passing away at old age or their wish to stay at home. One of the patients who was admitted and died had pre-existent severe dilating cardiomyopathy and emphysema with underlying malignancy; one patient suffered from chronic pulmonary obstructive disease and pre-existent lung disease due to rheumatoid arthritis and sarcoidosis. The sixth patient had a previous diagnose of complicated diabetes and obesity.
The total number of 27 SARS-CoV-2-positive patients out of 7600 (0.4%) is similar to that of the general population in the municipalities of our region, 120–900 per 100 000 inhabitants (0.12%–1%). The same holds true for the number of deaths: 0.08% in our population vs 0.041%–0.195% in the general population. Due to the restricted testing policy in the Netherlands, only patients with severe symptoms or healthcare workers were tested initially; in addition, patients in nursing homes were not systematically tested initially. Hence, the numbers on deaths and prevalence of COVID-19 in the general population are thought to be underestimated, and the comparison with our outpatient population warrants caution.
In line with the findings from Monti et al, we do not see a clear increased risk of complications requiring hospital admission for patients undergoing immunosuppressive treatment as compared with the general population in the municipality, even when taking into account that the patients in our outpatient clinic have a higher age as compared with the general population at risk in the municipalities in our region. We have to note, however, that our data are very preliminary and underpowered, and no definite conclusions can be drawn from our findings. Especially the number of out-of-hospital deaths and the full scale of patients with light symptoms that do not contact the hospital are not fully known to us. It is nevertheless reassuring to see that similar observations are made in Italy and the Netherlands for hospital admissions. As mentioned by Monti et al and underscored by Professor Dr McInnes,3 further large international efforts such as the EULAR-COVID-19 database are pivotal to provide further information of the impact of SARS-CoV-2 on our patient populations.
Contributors JB, RT and SB were involved in writing the article and in the data analyses. PV was involved in the data analyses.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.